Provider Demographics
NPI:1801436027
Name:LAKE, STACY MARRIE
Entity type:Individual
Prefix:MISS
First Name:STACY
Middle Name:MARRIE
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S 30TH ST TRLR 80
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1073
Mailing Address - Country:US
Mailing Address - Phone:702-277-1369
Mailing Address - Fax:
Practice Address - Street 1:1018 LUDINGTON ST
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-3541
Practice Address - Country:US
Practice Address - Phone:702-277-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist